Arterial ulcers are caused by decreased blood flow to the lower extremity. Diagnostics to confirm this diagnosis include arteriograms,color duplex angiography, magnetic resonance arteriogram, arterial doppler, and transcutaneous oxygen monitoring. Treatment typically is achieved by improving the circulation with a bypass graft or angioplasty. Typically these wounds are very painful, so a silicone dressing like Mepitel or wound veil is a good choice for the primary dressing (if the wound is not infected). If the arterial wound consists of dry gangrene then betadine can be painted or Iodosorb ointment (Smith and Nephew) placed over the gangrenous tissue ( to keep the gangrenous tissue dry). There is a high risk for amputation in patients who are unable to be revascularized or if the gangrene converts to wet or gas gangrene.

Venous ulcers form by a complex cascade of physiological events in the venous circulation related to venous hypertension. Diagnostics used to confirm venous hypertension include pneumoplethysmography (maximum venous outflow), venous photoplethysmography, and bi-directional color doppler.  Treatment for venous ulcers includes compression wrap bandages, intermittent pneumatic compression, and apligraf.

Diabetic wounds are related to microvascular and neuropathic changes in the diabetic patient. Diagnosis of the diabetic ulcer includes a compatible history of diabetes, monofilament test (to assess for loss of sensation), and noninvasive vascular assessments including a transcutaneous oxygen monitoring (TCOM) study. Treatment options for diabetic ulcers include off loading, growth factors (Regranex), debridement, and skin substitutes (Apligraf and Dermagraft).

A Biofilm is a surface-associated community that is composed of various types of microbes, which encases itself in a 3-dimensional matrix of extracellular polymeric substances (EPS) (e.g. polysaccharides, nucleic acids and proteins) and demonstrates increased resistance to cellular and chemical attack.

Microorganisms may exist in at least two distinct phenotypes – planktonic (free floating) and sessile (attached). A biofilm refers to a group or community of planktonic bacteria that may be incased in part of the extracellular matrix. The fragments have the ability to attach to another suitable surface and reform a biofilm community in the new area.

AAWC, (2008). Advancing your practice: Understanding wound infection and the role of biofilms. UKCT-A0021

Consider biofilm if the wound signs and symptoms includes:

Thick tenacious slough non-responsive (in the form of fast returning slough) to sharps debridement

Bright pink hypergranular tissue that bleeds easily

Wound bed has a slimy appearance

A biofilm may explain the delayed healing seen in some chronic wounds

Tx:

Serial Debridement

Alternate Silver (Acticoat) with Iodine based (Iodosorb)

Dakin’s solution 0.025 BID (for uncomplicated wounds)

Antibiotics

For more information connect to the center for biofilm engineering at Montana State University www.erc.montana.edu/

Dry Skin

Dry flakey skin – Moisturizer or thicker moisturizer.

Dry denuded skin – Xeroform

Dry lightly reddened skin – Topicort, change underlying padding to pure cotton cast padding.

Dry itching burning skin – Viscopaste wrap as first layer.

Moist Skin

Moist denuded skin – wound veil (Smith and nephew) covered with alginate. I recommend the wound veil cover because it will prevent the alginate from binding with the denuded tissue.

Draining wound – alginate or a beveled foam dressing. Note that foams have a tendency to dig into the skin around the edges, so it is important cut and taper around the foam edges.

Still Edematous

Swollen moist red skin with new breakdown (even with 30-40mmHg compression) – Typical with fluid over load patients including renal disease. Treat the  etiology.

Swollen extremity with reddened skin and new onset calf pain – Rule out DVT

Infection

Swollen red skin with open wound and new onset fever or pus – Rule out infection, culture wound, antibiotics.

Inflammation

Bright reddened skin   (Inflammatory with no signs of infection) – Topicort topical, medrol dose pack

Recurrent reddened skin with an open non-healing wound  – Consider differential diagnosis including autoimmune or another micro-occlusive disorder. Micro-occlusive disorders are covered in the Scottsdale Wound Management Guide (which can be purchased at swmghandbook.com). – Topicort to the wound bed and Prednisone oral weening over 6 weeks.

Dermatology

Reddened vessels around hair follicles – Rule out  folliculitus

Smaller reddened vessels (in groups or singular) – Consider treatment as fungal infection. Anti-fungal ointment for small area fungal breakouts.

Itchy rash over the majority of lower extremity below and maybe just above the knee (If using latex compression  wraps) , also possible systemic effects including puffy face, etc… – Rule out latex allergy, Consider Medrol dose pack, Benadryl, and Profore LF (Latex Free)

Shriveled skin – This is a common situation which happens during the first few weeks of compression therapy. The skin typically tightens on its own.

Pain

Vague recurrent pain with application of compression dressing – To much tension, consider less compression to the extremity. Including placing Tubigrip instead of Coban on the final layer. Insure that ABI indicates no arterial component.

Recurrent pain over bone with the application of compression dressing – Assess the skin for areas of bruising or open skin. Cover the area with a hydrocolloid.

Recurrent pain over small protruding bone with the application of compression dressing – Cut out foam around the prominence with the idea of offloading the small protruding bones from the pressure of the wrap.

Recurrent pain over prominent shin bone with the application of compression dressing – Build up an offloading  layer of cast padding to the shins sides.

Pain related to wrap cutting in to skin of fluted lower extremity.  Note that fluted refers to a thick upper calf and a narrow distal third of the lower extremity – Assess for rolled undulating skin with straight indentations or openings into the skin that match up with the wrap. Place extra cotton layers around the lower third of the dressing to build the area up. This protects the skin and helps prevent the wrap from sliding down.

Swollen extremity with reddened skin and new onset calf pain – Rule out DVT

This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot  and heel wounds.

Removable Cast Walker/ Walking Boots
1. Charcot Restraint Orthotic Walker  (CROW) boot:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot,  and heel wounds.
2. DH Walker (also known as Active Offloading Walker):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot,  and heel wounds.
3. Prefabricated Walker (any premade walking boot):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, ankle, and heel wounds.
4. Patella Tendon Bearing (PTB) brace:
This product is indicated for heel wounds.

Wedge Shoes
1. IPOS or Darco Wedge Shoe:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, and lateral metatarsal wounds.
2. Ortho Wedge Shoe:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, and lateral metatarsal wounds.
3. Reverse IPOS:
This product is indicated for offloading heel wounds (no longer manufactured)

Multipodus Splint / Boot (Prafo, L’nard, Bend-a-boot, Multiboot):
This product is indicated for offloading heel and ankle wounds.

Surgical Shoes or Shoes with Pressure relief Insoles
1. Post op shoe (e.g. the Darco med-surg shoe with “peg assist”):
This product is indicated for offloading dorsal digit wounds.
2. DH Pressure Relief shoe (also the DH offloading post-op shoe):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal,  lateral metatarsal wounds, and ankle wounds.
3. Plastizote Healing Shoe:
This product is indicated for offloading the dorsal digit, planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, and heel wounds.

1. Prewarm the past in a tray of warm water for a few minutes to make the paste less thick

2. Squeeze a little paste out on the clean side of the opened VAC kit package (let it sit for about a minute).

3. Pour a little water or normal saline into an appropriate container.

4. Dip into the water with a wood depressor or the back of the 10 blade scalpel (that you are using to cut the VAC foam)

5. Take up the stoma paste with the moist utensil surface and place it into the uneven surface. Leaving the top of the stoma paste even with the corresponding topside tissue. If you need to add more paste remember to re-moisten the utensil or else it will stick fast to the applicator.

6. Smooth out the paste between the inserted stoma paste with the corresponding topsided tissue by re-wetting the utensil and gently moving across it surface.

7. Wait a few minutes for the paste to firm and then apply the VAC drape over it. If you don’t wait for the stoma paste to firm up the VAC suction could pull it in, which could loose the seal.

AUTOIMMUNE DISORDER ULCERS

Clinical disorders lead to abnormal coagulation that triggers a primary thrombus in normal blood vessels leading to red cell blood clots, causing soft tissue cell death and ulceration.

CALCIPHYLAXIS

Condition associated with high levels of calcium phosphate. This leads to calcification of the small arteries (at the tunica media of the vessel). This is associated with intimal fibrosis and thrombus formation.

HEMATOLOGICAL ABNORMALITIES

Abnormal blood components lead to non flowing red blood cells and trigger blood clots.

LYMPHATIC OBSTRUCTION/ LYMPHEDEMA

Caused by a condition called lymphedema which typically doesn’t cause ulcerations (usually caused by trauma to the extremity), but the condition can keep wounds from closing.

MALIGNANCIES OF THE SKIN

More commonly related to (but not limited to) squamous cell carcinoma, basal cell carcinoma, and melanoma.

NECROBIOSIS LIPOIDICA

Associated with diabetes, which leads to collagen degeneration related to inflammation.

PYODERMA GANGRENOSUM

Pyoderma gangrenosum is an uncommon noninfectious neutrophilic dermatosis that is of an unknown cause.

RHEUMATOID ARTHRITIS ULCERS

Rheumatoid arthritis is a systemic autoimmune disorder of unknown etiology.

SCLERODERMA

Condition related to the occlusion of finger (digital) blood vessels related to excess collagen deposition inside the vessels

SICKLE CELL ULCERS

Related to the condition of sickle cell anemia. Unique sickle formed red blood cell clot and therefore, prevents appropriate capillary flow and tissue perfusion.

VASCULITIS/VASCULOPATHY

With vasculitis abnormal blood vessels activate a red blood cell clot.

WARFARIN (COUMADIN®) NECROSIS

Related to starting warfarin therapy. This condition is related to a protein C deficiency with anti-vitamin K anticoagulants leading to a hypercoagulable condition that results in a blood clot of skin (dermal) vessels.